In the US alone, more than 2 million Americans will be diagnosed in 2010 with nonmelanoma skin cancer, and 68,130 will be diagnosed with melanoma, according to the American Cancer Society.
Fortunately, skin cancers (basal cell and squamous cell carcinoma, and malignant melanoma) are rare in children. When melanomas occur, they usually arise from pigmented nevi (moles) that are large (diameter greater than 6 mm), asymmetric, with irregular borders and coloration. Bleeding, itching, and a lump under the skin are other signs of cancerous change. If a child has had radiation treatment for cancer, moles in the radiated area are at increased risk of becoming cancerous.
In this segment, Carrie Coughlin, MD, Washington University pediatric dermatologist at St. Louis Children's Hospital, discusses nevi (moles) and melanoma in children and when to refer to a specialist.
Nevi (moles) and Melanoma
Featured Speaker:
Learn more about Carrie C. Coughlin, MD
Carrie Coughlin, MD
Carrie Coughlin, MD, is a Washington University pediatric dermatologist at St. Louis Children’s Hospital.Learn more about Carrie C. Coughlin, MD
Transcription:
Melanie Cole (Host): According to the American Cancer Society, in the US alone, more than 2 million Americans will be diagnosed with non-melanoma skin cancer and many more will be diagnosed with melanoma. Fortunately, skin cancers are rare in children; however, they do happen. My guest today is Dr. Carrie Coughlin. She's a Washington University Pediatric Dermatologist at St. Louis Children's Hospital. Welcome to the show, Dr. Coughlin. What are moles or nevii? What should a pediatrician look for?
Dr. Carrie Coughlin (Guest): So, moles are generally pigmented spots on the skin, meaning they are brown spots on the skin that can be present from birth or that children can acquire as they get older. Nevii is the plural form of nevus, and just means multiple moles on the skin. Pediatricians will look for size, shape, color, and change because in children, it's really change or symptoms such as itch or bleeding that can be concerning signs.
Melanie: Are there different types of moles?
Dr. Coughlin: There are. There are congenital moles, so ones that you're born with that can be larger and darker than other moles. Some of those are graded by size. You can even have small ones that are less than a centimeter and a half, you can have medium-sized ones, large, and giant congenital nevii, meaning ones that are larger than 40 centimeters. They can also have satellites, so small, brown spots that are scattered over the skin, that are also considered congenital nevii, and then there are regular acquired nevii that people develop over time, sometimes for by sunlight, and sometimes in people's genetics.
Melanie: What is the relation between nevii and melanoma?
Dr. Coughlin: Some melanomas form from moles and they can be from acquired moles or from congenital moles. Then, other melanomas appear de novo, meaning arise from normal skin. The trick with melanoma is that it doesn't always have to be brown, especially in children, you can see many melanomas that are pink or red and can mimic other growths on the skin, and those can be a little bit trickier to diagnose.
Melanie: So, what are some of the signs and symptoms of melanoma and give pediatricians a working lesson on how to perform a thorough skin examination.
Dr. Coughlin: Sure. So, I'll start with the latter part of the question first. A thorough skin exam really does mean from scalp to feet and everywhere in between. So, for any new patient that comes to my office, we have them change into a gown so we can literally look from the top of the head, chest, belly, back, look under the underwear to make sure there's nothing hiding out there, and all the way down the arms and the legs. We look at palms and soles, as well, and even between the toes, because those are areas that kids don't always check for themselves. In terms of recognizing concerning lesions, it's really that ABCDE's and I think folks are familiar with them for adults, but the criteria are a little bit different in children. There is a great study by Cordoro, et al looking at ABCDE's in children and it really is amelanotic, meaning without color. So, oftentimes those melanomas in children can be pink or red or shiny, like we talked about a little bit earlier. The borders can be irregular. We've talked about color. You can have really dark areas or really light areas, and then you can have change. So, change is a big thing, in terms of recognizing a concerning lesion in a child.
Melanie: And, are there some risk factors? What would you like pediatricians to advise their patients about if there are risk factors?
Dr. Coughlin: There are definitely risk factors. So, we know that UV exposure to sunlight is definitely a risk factor in terms of developing atypical moles or melanoma. Tanning beds are definitely risk factors for developing melanoma. We counsel all of our patients strongly to avoid those. And then, genetics can be a risk factor. So, people who are fair skinned, light hair, or have melanoma in a first-degree relative or family history, even there are some melanoma syndromes, so familial atypical mole and melanoma syndrome where you can get a family history and figure out if somebody seems like they have that. So, if there's pancreatic cancer, brain cancer, and melanoma in a family, you're going to be suspicious that they might have one of those syndromes and do some genetic testing to then risk stratify people.
Melanie: When should a pediatrician refer to a specialist?
Dr. Coughlin: I always say it's nice to have things on the skin because you can see them and if you're worried about it, you may as well send them on over, because I can see it, as well. But a few things are more concerning. So, if you have a bump that you think is a pyogenic granuloma, or benign vascular growth that pops up in a child who it's not just present at birth, but grows and then stays the same size, doesn't quite look right to you, you don't think it's a hemangioma, but you don't quite know what it is, that's the sort of spot that could be a melanoma in a child that would be pretty suspicious. Of course, most of those in children are going to be pyogenic granulomas or angiomas, benign blood vessel things, but that's where sometimes melanomas can hide out, and that's why we send all of those to pathology when we do biopsy. Or, somebody who has a mole that they are really noticing changing. It's particularly itchy or has bled, because moles should not be itchy and they should not bleed. Anyone who has a congenital nevus that's on the larger size, so, say 10, 20 centimeters, and develops a nodule underneath it because melanomas can be tricky and people who have congenital nevii, it can actually appear in the second layer of the skin rather than on the top of the skin. So, it could even look like something is benign as a cyst, but actually be a melanoma in that second layer of the skin.
Melanie: How can the melanoma nevii clinic at St. Louis Children's Hospital help these patients?
Dr. Coughlin: Well, we are fortunate to be starting this out in May of this year. The clinic is a great collaboration between hematology/oncology, pediatric dermatology, pediatric otolaryngology, pediatric surgery, and pediatric plastic surgery as well as having the support of genetics, and dermatopathology, and radiology to really do comprehensive, collaborative care for patients who have more difficult lesions that either: A) have a questionable diagnosis; or, B) are going to need multiple specialists in their care. So, for these patients with concerning atypical moles or a mole that was biopsied by an outside provider that is suspicious for a melanoma, this is a great home for patients to come so patients can see me as the dermatologist, they can see a plastic surgeon who may need to do a wider excision if it's on the face, and if, depending on the type of melanoma, they may need to have some adjunctive medical treatment, would talk to oncology as well. So, we're going to have monthly conferences where we run through our patients together as a team. So, it's a way to really coordinate multi-disciplinary care so that patients aren't traveling back and forth as often, are seeing the specialists they need to see, and then are assured that we are all communicating well, as well.
Melanie: And, what can a pediatrician expect from your team at St. Louis Children's Hospital after referring a patient to you?
Dr. Coughlin: Even upon the initial referral, we get basic information and we'll often request records ahead of time, so that we can provide kind of more efficient care when patients come to the clinic. Afterwards, our notes will be generated and will cycle back to pediatricians and we often call to talk about what the plan of care is going to be for some our patients who have more challenging or complex diagnoses. So, we do give back information to pediatricians as well as let you know what to anticipate in terms of their follow up with us, and then make sure that you are comfortable with what the plan is and if there are any questions or concerns, we address that as well. To refer a patient to the Pediatric Melanoma and Nevus Clinic, you can call 314-454-2714. That's the Pediatric Dermatology line, and choose option 5, for our nurse line. Leave the patient's name, date of birth, and contact information, as well as your name and contact information and the diagnosis that you're suspecting so that we can coordinate care.
Melanie: And in summary, Dr. Coughlin, tell other pediatricians what you'd like them to know about recognizing nevii, or moles, and when they should refer.
Dr. Coughlin: My main message as a pediatric dermatologist is sun protection, sun protection, sun protection, to really help kids avoid collecting some of the atypical nevii and melanoma that are due to UV radiation. Otherwise, I recommend feeling free to send over anyone who has larger, giant congenital melanocytic nevii, concerning spots on the skin, family history of melanoma or atypical nevii, or really just spots that you look at as a pediatrician, and in your gut, you think this is not quite right. Those are the ones that we want to see. We help triage in terms of who else within Children's they should see on the same day to help make their visit more worthwhile.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): According to the American Cancer Society, in the US alone, more than 2 million Americans will be diagnosed with non-melanoma skin cancer and many more will be diagnosed with melanoma. Fortunately, skin cancers are rare in children; however, they do happen. My guest today is Dr. Carrie Coughlin. She's a Washington University Pediatric Dermatologist at St. Louis Children's Hospital. Welcome to the show, Dr. Coughlin. What are moles or nevii? What should a pediatrician look for?
Dr. Carrie Coughlin (Guest): So, moles are generally pigmented spots on the skin, meaning they are brown spots on the skin that can be present from birth or that children can acquire as they get older. Nevii is the plural form of nevus, and just means multiple moles on the skin. Pediatricians will look for size, shape, color, and change because in children, it's really change or symptoms such as itch or bleeding that can be concerning signs.
Melanie: Are there different types of moles?
Dr. Coughlin: There are. There are congenital moles, so ones that you're born with that can be larger and darker than other moles. Some of those are graded by size. You can even have small ones that are less than a centimeter and a half, you can have medium-sized ones, large, and giant congenital nevii, meaning ones that are larger than 40 centimeters. They can also have satellites, so small, brown spots that are scattered over the skin, that are also considered congenital nevii, and then there are regular acquired nevii that people develop over time, sometimes for by sunlight, and sometimes in people's genetics.
Melanie: What is the relation between nevii and melanoma?
Dr. Coughlin: Some melanomas form from moles and they can be from acquired moles or from congenital moles. Then, other melanomas appear de novo, meaning arise from normal skin. The trick with melanoma is that it doesn't always have to be brown, especially in children, you can see many melanomas that are pink or red and can mimic other growths on the skin, and those can be a little bit trickier to diagnose.
Melanie: So, what are some of the signs and symptoms of melanoma and give pediatricians a working lesson on how to perform a thorough skin examination.
Dr. Coughlin: Sure. So, I'll start with the latter part of the question first. A thorough skin exam really does mean from scalp to feet and everywhere in between. So, for any new patient that comes to my office, we have them change into a gown so we can literally look from the top of the head, chest, belly, back, look under the underwear to make sure there's nothing hiding out there, and all the way down the arms and the legs. We look at palms and soles, as well, and even between the toes, because those are areas that kids don't always check for themselves. In terms of recognizing concerning lesions, it's really that ABCDE's and I think folks are familiar with them for adults, but the criteria are a little bit different in children. There is a great study by Cordoro, et al looking at ABCDE's in children and it really is amelanotic, meaning without color. So, oftentimes those melanomas in children can be pink or red or shiny, like we talked about a little bit earlier. The borders can be irregular. We've talked about color. You can have really dark areas or really light areas, and then you can have change. So, change is a big thing, in terms of recognizing a concerning lesion in a child.
Melanie: And, are there some risk factors? What would you like pediatricians to advise their patients about if there are risk factors?
Dr. Coughlin: There are definitely risk factors. So, we know that UV exposure to sunlight is definitely a risk factor in terms of developing atypical moles or melanoma. Tanning beds are definitely risk factors for developing melanoma. We counsel all of our patients strongly to avoid those. And then, genetics can be a risk factor. So, people who are fair skinned, light hair, or have melanoma in a first-degree relative or family history, even there are some melanoma syndromes, so familial atypical mole and melanoma syndrome where you can get a family history and figure out if somebody seems like they have that. So, if there's pancreatic cancer, brain cancer, and melanoma in a family, you're going to be suspicious that they might have one of those syndromes and do some genetic testing to then risk stratify people.
Melanie: When should a pediatrician refer to a specialist?
Dr. Coughlin: I always say it's nice to have things on the skin because you can see them and if you're worried about it, you may as well send them on over, because I can see it, as well. But a few things are more concerning. So, if you have a bump that you think is a pyogenic granuloma, or benign vascular growth that pops up in a child who it's not just present at birth, but grows and then stays the same size, doesn't quite look right to you, you don't think it's a hemangioma, but you don't quite know what it is, that's the sort of spot that could be a melanoma in a child that would be pretty suspicious. Of course, most of those in children are going to be pyogenic granulomas or angiomas, benign blood vessel things, but that's where sometimes melanomas can hide out, and that's why we send all of those to pathology when we do biopsy. Or, somebody who has a mole that they are really noticing changing. It's particularly itchy or has bled, because moles should not be itchy and they should not bleed. Anyone who has a congenital nevus that's on the larger size, so, say 10, 20 centimeters, and develops a nodule underneath it because melanomas can be tricky and people who have congenital nevii, it can actually appear in the second layer of the skin rather than on the top of the skin. So, it could even look like something is benign as a cyst, but actually be a melanoma in that second layer of the skin.
Melanie: How can the melanoma nevii clinic at St. Louis Children's Hospital help these patients?
Dr. Coughlin: Well, we are fortunate to be starting this out in May of this year. The clinic is a great collaboration between hematology/oncology, pediatric dermatology, pediatric otolaryngology, pediatric surgery, and pediatric plastic surgery as well as having the support of genetics, and dermatopathology, and radiology to really do comprehensive, collaborative care for patients who have more difficult lesions that either: A) have a questionable diagnosis; or, B) are going to need multiple specialists in their care. So, for these patients with concerning atypical moles or a mole that was biopsied by an outside provider that is suspicious for a melanoma, this is a great home for patients to come so patients can see me as the dermatologist, they can see a plastic surgeon who may need to do a wider excision if it's on the face, and if, depending on the type of melanoma, they may need to have some adjunctive medical treatment, would talk to oncology as well. So, we're going to have monthly conferences where we run through our patients together as a team. So, it's a way to really coordinate multi-disciplinary care so that patients aren't traveling back and forth as often, are seeing the specialists they need to see, and then are assured that we are all communicating well, as well.
Melanie: And, what can a pediatrician expect from your team at St. Louis Children's Hospital after referring a patient to you?
Dr. Coughlin: Even upon the initial referral, we get basic information and we'll often request records ahead of time, so that we can provide kind of more efficient care when patients come to the clinic. Afterwards, our notes will be generated and will cycle back to pediatricians and we often call to talk about what the plan of care is going to be for some our patients who have more challenging or complex diagnoses. So, we do give back information to pediatricians as well as let you know what to anticipate in terms of their follow up with us, and then make sure that you are comfortable with what the plan is and if there are any questions or concerns, we address that as well. To refer a patient to the Pediatric Melanoma and Nevus Clinic, you can call 314-454-2714. That's the Pediatric Dermatology line, and choose option 5, for our nurse line. Leave the patient's name, date of birth, and contact information, as well as your name and contact information and the diagnosis that you're suspecting so that we can coordinate care.
Melanie: And in summary, Dr. Coughlin, tell other pediatricians what you'd like them to know about recognizing nevii, or moles, and when they should refer.
Dr. Coughlin: My main message as a pediatric dermatologist is sun protection, sun protection, sun protection, to really help kids avoid collecting some of the atypical nevii and melanoma that are due to UV radiation. Otherwise, I recommend feeling free to send over anyone who has larger, giant congenital melanocytic nevii, concerning spots on the skin, family history of melanoma or atypical nevii, or really just spots that you look at as a pediatrician, and in your gut, you think this is not quite right. Those are the ones that we want to see. We help triage in terms of who else within Children's they should see on the same day to help make their visit more worthwhile.
Melanie: Thank you so much for being with us today. A physician can refer a patient by calling Children's Direct Physician Access Line at 1-800-678-HELP. That's 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.